ACUTE CORONARY

SYNDROME
 Ischemic Chest Pain Algorithm
Chest pain
suggestive of ischemia

Immediate assessment (<10 minutes) Immediate general treatment EMS personnel can
perform immediate
Measure vital signs (automatic/standard BP cuff) Oxygen at 4 L/min
assessment and
Measure oxygen saturation Aspirin 160 to 325 mg treatment (MONA),
Obtain IV access Nitroglycerin SL or spray including initial 12-lead
Obtain 12-lead ECG (physician reviews) Morphine IV (if pain not relived with ECG and review for
Perform brief, targeted history and physical exam; nitroglycerin) fibrinolytic therapy
focus on eligibility for fibrinolytic therapy indications and
contraindications.
Obtain initial serum cardiac marker levels Memory aid: MONA greets all patients
Evaluate initial electrolyte and coagulation studies (Morphine, Oxygen, Nitroglycerin,
Request, review portable chest x-ray (<30 minutes) Aspirin)

Assess initial 12-lead ECG

ST elevation or new or ST depression or dynamic T-wave Nondiagnostic ECG: absence of

presumably new LBBB: inversion: strongly suspicious for change in ST segment or T
strongly suspicion for injury lachemia waves
ST-elevation AMI High-risk unstable angina/ non-ST Intermediate/low-risk unstable
elevation AMI angina
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 Start adjunctive treatments
(as indicated: no reperfusion delay)
-Adrenoceptor blockers IV
Nitroglycerin IV
Heparin IV
ACE inhibitors (after 6 hours or
when stable)
Time from onset of symptoms
<12 hours
Select a reperfusion
strategy based on local
resources:
Angiography
PCI (angioplasty stent)
Cardiothoracic surgery
backup
Start adjunctive treatments
(as indicated: no contraindications)
Heparin (UFH/LMWH) Meets criteria for unstable
Aspirin 160 to 325 mg qd Yes or new-onset angina?
Glycoprotein IIb/IIIa receptor Or
inhibitors Troponin positive?
Nitroglycerin IV
No
-Adrenergic receptor blockers
>12 hours Admit to ED chest pain
Assess clinical status unit
Or to monitored bed
if signs of cardiogenic shock High-risk patient: defined Clinically In ED follow
or contraindications to by stable
fibrinolytics, PCI is treatment serial cardiac markers
of choice (Class I) if available Persistent symptoms (including troponin)
If PCI is not available, use Recurrent ischemia Repeat
fibrinolystics (if no
contraindications) Depressed LV function ECG/continuos ST
monitoring
Widespread ECG changes
Consider imaging
Prior AMI, PCI, CABG study (2D
echocardiogharphy or
radionuclide)
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 No Yes
Fibrinolytic therapy selected Primary PCI selected Perform cardiac Evidence
catheterization: of ishemia
Front-loaded alteplase or Door-to-ballon
anatomy suitable for Admit to CCU/ monitored bed or
inflation 90 30
Streptokinase or revascularization?
minutes Continue or start adjunctive infraction
APSAC or treatments as indicated
Experienced
Yes No
Reteplase or operators Serial cardiac markers
Discharge
Tenecteplase High-volume center Revascluraization Serial ECG
acceptable
Goal: door-to-drug <30 Cardiac surgical PCI Consider imaging study (2D
Arrange
minutes capabillity echocardiography or raionuclide)
CABG follow-up

This algorithm provides general guidelines that may not apply to all patients. Carefully consider proper indications and contraindications.
 The Acute Coronary Syndromes
Assess the initial ECG

The 12-lead ECG is central to triage of ACS in the Emergency

Department
Classify patients as being in 1 of 3 syndromes within 10 minutes of
arrival

ST-segment elevation or ST-segment depression/ Nondiagnostic or normal

new LBBB dynamic T-wave Inversion: ECG
strongly suspicious for
ischemia

ST elevation 1 mm in 2 or ST depression >1 mm ST depression 0.5 to 1.0 mm

more contiguous leads
Marked symmetrical T-wave T-wave inversion or flattening
New or presumably new inversion in multiple precordial leads in leads with dominant R waves
LBBB (BBB obscuring ST-
Dynamic ST-T changes with pain Normal ECG
segment analysis)

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 >90% of patients with ischemic-
type chest pain and ST-segment
elevation will develop new Q waves
or positive serum markers for AMI.
Patients with hyperacute T waves
benefit when AMI diagnosis is
certain. Repeat ECG may be
helpful.
Patients with ST depression in
early precordial leads who have
posterior MI benefit when AMI
diagnosis is certain
Reperfusion therapy
Aspirin
Heparin (if using fibrin-
specific lytics)
-Blockers
Nitrates as indicated
High-risk subgroup with increased
mortality:
Persistent symptoms, recurrent
ischemia
Diffuse or widespread EG
abnormalities
Depressed LV function
Congestive heart failure
Serum marker release: positive
troponin or CK-MB+
Antithrombin therapy with
heparin
Antiplatelet therapy with
aspirin
Glycoprotein Iib/Iia Inhibitors
-Blockers
Nitrates
Heterogeneous group: rapid
assessment needed by
Serial ECGs
ST-segment monitoring
Serum cardiac markers
Further risk assessment helpful
Perfusion radionuclide imaging
Stress echocardiography
Aspirin
Other therapy as
appropite
Patients with positive
serum markers, ECG
changes, or functional
study: manage as high
risk
SELESAI